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In Brief:

Over the past 15 years, there has been an extreme “escalation of documentation” requirements for attending physicians and surgeons in academic and private practice. The added documentation burdens are impacting the ability to achieve high quality performance in operating room environments. Furthermore, they are having significant negative impacts on provider morale.

Abstract:

In Brief:

A systematic review and meta-analysis were performed to evaluate the impact of resident duty hours (RDH) on clinical and educational outcomes in surgery. A total of 135 articles met inclusion criteria. In surgery, recent RDH changes are not consistently associated with improved resident well-being and may have negative impacts on patient outcomes and education.

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In Brief:

Our combined analysis showed that there was a difference in operative time (1–9 minutes), whereas, there were no differences in pain (chronic or acute) or other complications between the self-gripping mesh and conventional sutured Lichtenstein procedure.

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It is unknown whether hospital performance on publicly reported quality measures differs by cancer accreditation. We found that accredited cancer centers performed better on most process and patient experience measures but worse performance on most outcome measures. These discordant findings emphasize the need to focus on oncology-specific measurement strategies.

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In patients with achalasia, per-oral endoscopic myotomy (POEM) was compared with Heller myotomy (HM) for postoperative symptoms, 6-month pH/esophageal manometry. POEM provides equivalent or better relief of dysphagia with similar rates of acid exposure to HM, using a less invasive modality with a shorter hospitalization.

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Long-term prospective data on nutritional complications after gastric bypass (GBP) are missing. We assessed nutritional deficiencies in 144 subjects at 3 years or later after GBP and concluded that monitoring of several nutritional parameters is required in the long term to avoid deficits that are not corrected by standard multivitamin preparations.

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Retrospective analysis of data from American College of Surgeons National Surgical Quality Improvement Program suggests that local repair alone is the preferred surgical approach for perforated peptic ulcer disease but that vagotomy/drainage may result in lower postoperative mortality than local ulcer oversew for patients who require emergency operation for intractable ulcer bleeding.

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Concerns about health care outcomes and costs have driven the need to measure quality. To meet this need, we introduce the HARM score, a novel tool based on length of stay, admission type, discharge status, and 30-day readmissions. We validate the HARM score on a national sample and show benefits over existing tools.

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This study describes the outcome of sacral nerve stimulation for fecal incontinence at 5 years for more than 100 patients, including analysis of predictive factors and adverse events during the course of treatment.

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A role for genetics in the pathophysiology of diverticulitis is suggested by the presence of disease in multiple, young family members and its association with other inherited disorders. We investigated single nucleotide polymorphisms in the anti-angiogenic and immune regulatory gene TNFSF15 and found (the G allele within) rs7848647 to be associated with surgical diverticulitis in a discovery group of 21 patients and a separate test group of 34 patients. Similarly, 5 members of a single family suffering from relatively youthful diverticulitis were homozygous for this ‘at risk’ allele.

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In the Netherlands, the results of circumferential margin involvement after abdominoperineal excision are not inferior to low anterior resection and are much more beneficial in comparison to earlier reports. Standardization of preoperative treatment, operative technique, pathologic examination and quality control by clinical auditing may have contributed to these positive findings.

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Optimization of the detection of venous invasion in colorectal cancer using elastica stains improves its prognostic value to a level comparable with lymph node involvement. Combining T stage and venous invasion results in more accurate stratification of cancer specific survival than classical TNM staging especially in early stage disease.

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In Brief:

Perineal/perianal rhabdomyosarcomas are rare tumor and have an unsatisfactory outcome requiring multimodal treatment approaches. Several prognostic factors have been identified, and quality of life and fecal continence are limited.

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In left hemihepatectomy for hilar cholangiocarcinoma of the left-side predominance, vasculobiliary anatomy of the right liver often makes it difficult to achieve a tumor-free margin of the right posterior sectional bile duct. Therefore, we have expanded the indications for left trisectionectomy over the last 5 years. Our recent strategy resulted in improved R0 resection rates without affecting postoperative mortality, thus leading to better survival after surgery.

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Avoidance of futility in the sickest liver transplant recipients presents a major challenge for every transplant center. Posttransplant futility in recipients with highest Model of End-Stage Liver Disease scores (=40) is primarily determined by recipient's disease-specific factors rather than demographic, donor, or surgery-related characteristics.

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In this study, 473 separate hepatic microwave ablation procedures were reviewed from 4 high-volume centers to determine influential variables in local control. Size was the most influential factor, where tumors 3 cm or more in size showed a propensity for early recurrence and negatively influenced overall survival, regardless of histology.

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In this study, we collected the medical records of 447 patients with necrotizing pancreatitis from January 2009 to June 2012. Data associated with organ failure and infection were analyzed. This study demonstrated that compared with infection, organ failure is a more critical determinant of mortality in patients with necrotizing pancreatitis.

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We developed a model of the decision to operate on a patient with pancreatic adenocarcinoma based on a theory of regret. After developing a survival model based on available preoperative information, we showed that adherence to a model based on a surgeon's level of regret for operating on a patient who would not be helped with resection and not operating on a patient who would be helped is superior to strategies of operating on all potentially resectable patients or operating on no one.

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Guidelines for surveillance of patients with resected melanoma are not evidence based. In this study, we modeled the predictive value and clinical impact of surveillance imaging strategies. We found that routine imaging had limited value in detecting treatable recurrences for all stages of disease.

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Nationwide, Swedish registers were used to assess the incidence of groin hernia repair after radical prostatectomy for prostate cancer compared with the incidence in a control population. An almost 4-fold increase in groin hernia repair was observed after radical prostatectomy compared with controls.

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In this study of 13,328 patients treated with appendicitis at 34 children's hospitals, significant variation in practice was found spanning all aspects of diagnosis and management, including the use of diagnostic imaging, parenteral nutrition, peripherally inserted central catheter lines, and treatment-related hospital cost. Outliers on the basis of high and low utilization were identified for all measures.

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Atorvastatin attenuates neuroinflammation and improves cognitive function in mice after surgery in a model of postoperative cognitive dysfunction (POCD). The data reported here indicate that the anti-inflammatory and neuroprotective properties of atorvastatin provide a rationale for its use as a therapeutic strategy for POCD.

Surgical Retrospection

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In Brief:

Ton That Tung has been recognized as the father of Vietnamese surgery. This was, in part, due to his interest in and contributions toward an understanding of liver anatomy and liver surgery. Importantly, he based his surgical approach to liver resection first and foremost on a thorough understanding of liver anatomy.